Ischemic Heart Disease - Cleveland Clinic

Cardiac Catheterization Laboratory Procedures (N = 10,818)

Cleveland Clinic is a regional and national referral center for percutaneous coronary intervention (PCI). In 2011, we performed more than 10,000 procedures for patients with simple and complex ischemic disease.

Data comparisons represent Cleveland Clinic’s outcomes with patients at hospitals included in the American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR) Cath-PCI Registry® for hospitals that perform > 500 PCIs/year. All comparison data are based on a one-year rolling average. Therefore, there may be differences compared with totals reported elsewhere in this book.

Use of Adjunctive Medications Before and After PCI (N = 1,833)2011

100

95

80Aspirin on Admission

Before Procedure

Statins Thienopyridines

At Discharge

Aspirin

90

85

PercentCleveland ClinicComparable ACC-NCDR Hospitals

One of the ACC-NCDR key performance measures is the use of appropriate adjunctive medications before and after PCI procedures. Compared with the average high-volume interventional center, Cleveland Clinic exceeds the rate of administration for all these medications.

60

50

0Age

(> 75 years)Prior MIAcute Care

TransferPrior Heart

FailurePrior CABG Severe LV

DysfunctionMultivessel

DiseaseDiabetes

40

30

20

10

Percent Comparable ACC-NCDR HospitalsCleveland Clinic

Ischemic Heart Disease

Risk Factors Among Patients Undergoing PCI Procedures (N = 1,833)2011

In many cases, patients who had PCI procedures at Cleveland Clinic in 2011 had more complex medical backgrounds than patients at comparable hospitals.

13

Abbreviations: CABG, coronary artery bypass grafting; LV, left ventricular; MI, myocardial infarction.

Sydell and Arnold Miller Family Heart & Vascular Institute

14

4

3

0Risk-Adjusted Mortality Major Vascular Complications

2

1

Percent

Comparable ACC-NCDR HospitalsCleveland Clinic

Patients who had PCI procedures at Cleveland Clinic in 2011 had fewer complications (mortality, major vascular complications) than patients at comparable hospitals.

Ischemic Heart Disease (continued)

PCI Complications2011

Door-to-Balloon Time (N = 55)*2011

*A total of 55 patients treated for myocardial infarc-tion at Cleveland Clinic’s ED met the ACC-NCDR reporting criteria for a primary diagno-sis of STEMI. Among these patients, time for reperfusion was 58 minutes. The rate at comparable hospitals was 62 minutes.

The American College of Cardiology/American Heart Association (ACC/AHA) practice guidelines recommend PCI balloon inflation within 90 minutes of arrival in the emergency department (ED) for patients with ST-elevation myocardial infarction (STEMI). Early reperfusion reduces the risk of morbidity and mortality.

80

100

6260

0Cleveland Clinic Comparable ACC-NCDR

Hospitals ACC/AHA Goal

40

20

Minutes

58

90

4

3

0Cleveland Clinic O/E RatioComparable ACC-NCDR

Hospitals

2

1

Percent

ExpectedObserved

PCI Mortality2011

The observed rates of mortality for patients who had PCI procedures at Cleveland Clinic in 2011 were lower than expected, resulting in a favorable O/E ratio.

Outcomes 2011

15

Surgical Treatment for Ischemic Heart Disease

CABG Volume (N = 1,355)2011

CABG Volume, Primary and Reoperations2011

CABG + Other, Mortality2011

Cleveland Clinic’s mortality rate for patients who had CABG plus another procedure was less than half of the expected rate, despite the fact that nearly one quarter of all these operations were reoperations, which are generally more complex with increased risk.

77% Primary Operations77% Primary Operations

23% Reoperations 23% Reoperations

100%100%

Procedure Volume

Isolated 527

CABG + Other 828

In 2011, Cleveland Clinic performed 1,355 coronary artery bypass grafting (CABG) procedures. A total of 527 were isolated procedures (performed without any other operation), and 828 were performed in combination with another procedure.

Primary procedures (patients’ first CABG) accounted for the majority of all CABG surgeries.

00

66

Cleveland Clinic Expected

22

44

PercentPercent

Primary Reoperation

44

PercentPercent

33

22

11

00

ExpectedCleveland Clinic

Source: University HealthSystem Consortium 2011 discharges.Source: University HealthSystem Consortium 2011 discharges.


16

★★★

★★


Cleveland Clinic is among

the 15 percent of hospitals

that achieved an overall

three-star rating from

The Society of Thoracic

Surgeons (STS) for CABG

surgery. The rating reflects

the highest quality of

cardiac surgery.

*Based on data comparisons from January 2011 through December 2011.

Primary (N = 459) Reoperation (N = 68)

44

PercentPercent

33

22

11

00

Expected

0%

Observed

Isolated CABG Procedures Mortality

In 2011, Cleveland Clinic surgeons performed 527 isolated CABG procedures with lower-than-expected mortality.

Source: University HealthSystem Consortium 2011 discharges.

Source: Society of Thoracic Surgeons (STS) National Adult Cardiac Surgery Database, 2011.

STS CABG Quality Ratings*

Overall

Use of Internal Mammary Artery

Medications

Avoidance of Mortality

Avoidance of Morbidity

5

4

0Q1 Q3 Q4Q2

3

2

1

Percent

Cleveland ClinicSTS Expected

0% 0% 0%

Isolated CABG Mortality – Primary and Reoperation

Because of our expertise, we often receive referrals for reoperations. These are associated with greater morbidity and mortality than are primary procedures. Despite increased risks, overall mortality for isolated CABG remained low.

Outcomes 2011Outcomes 2011

17

Primary Isolated CABG: Age-Related Risk of Mortality

2011 Age Observed Mortality (%) Expected Mortality (%)

< 50 years (N = 50) 0.0 1.0

50–59 years (N = 113) 0.9 1.0

60–69 years (N = 165) 0.6 1.2

70–79 years (N = 98) 1.0 2.7

≥ 80 years (N = 33) 0.0 4.0

Total (N = 459) 0.6 1.6

5

4

0Q1 Q3 Q4Q2

3

2

1

Percent


0% 0% 0% 0%

Isolated CABG: Additional Outcomes

In addition to mortality, other outcomes for isolated CABG at Cleveland Clinic contributed to the achievement of a Three-Star STS quality rating.


Age contributes to the complexity of CABG surgical cases. The majority of patients who had primary isolated CABG surgery in 2011 at Cleveland Clinic were age 60 and older.

Deep Sternal Wound Infection2011

Throughout 2011, Cleveland Clinic maintained a 0 percent incidence of deep sternal wound infection following isolated CABG surgery.


18

20

0Q1 Q3 Q4Q2

15

10

5

Percent


20

0Q1 Q3 Q4Q2

15

10

5

Percent


10

0Q1 Q3 Q4Q2

8

6

4

2

Percent


Ventilator Time > 24 Hours

Cleveland Clinic continues to work toward reducing the number of patients who require a ventilator for more than 24 hours after isolated CABG surgery. Reduced ventilator time leads to better outcomes and increased patient satisfaction.

In-Hospital Reoperation

Cleveland Clinic’s rate of in-hospital reoperation after CABG surgery was consistently below the expected rate throughout 2011.

Postoperative Stroke

Cleveland Clinic continues to work toward reducing the incidence of stroke after isolated CABG surgery.





Outcomes 2011

Acute Myocardial Infarction (AMI) Appropriateness of Care – National Hospital Quality Measures

2010 – 2011

This composite metric, based on eight acute myocardial infarction hospital quality process measures developed by the Centers for Medicare and Medicaid Services (CMS), shows the percentage of patients who received all the recommended care for which they were eligible. Cleveland Clinic has set a target of UHC’s 90th percentile.

19

0

60

40

20

80

100Percent

98.6 97.0 99.3

Cleveland Clinic UHC Top Decile*

2010 20112011

Cleveland Clinic, 2010

Cleveland Clinic, 2011

UHC Top Decile, 2011*

10

0Q1 Q3 Q4Q2

8

6

4

2

Percent


0%

100

0Q1 Q3 Q4Q2

80

60

40

20

Percent

Postoperative Renal Failure

In 2011, we improved the rate of postoperative renal failure following CABG surgery.

Process Measures

Cleveland Clinic achieved and maintained 100 percent compliance with all Society of Thoracic Surgeons (STS) process measures in 2011. These include the use of a peri-operative beta blocker; beta blocker, statin, and aspirin at discharge; and use of an internal mammary artery during isolated CABG surgery.



Source: University HealthSystem Consortium (UHC) Clinical Database. https://www.uhc.edu


0

5

10

15

20

25

30

Percent

National Average*

19.722.1

Cleveland Clinic

AMI All-Cause 30-Day Mortality (N = 385)

July 2008 – June 2011

Source: www.hospitalcompare.hhs.gov

AMI All-Cause 30-Day Readmission (N = 662)

July 2008 – June 2011

0

5

10

15

20

25

30

Percent

National Average*

15.515.0

Cleveland Clinic

Source: www.hospitalcompare.hhs.gov

Acute Myocardial Infarction (AMI) – National Hospital Quality Measures (continued)

Cleveland Clinic’s AMI risk-adjusted all-cause 30-day mortality rate is slightly below the national average; the difference is not statistically significant. Our AMI risk-adjusted readmission rate is higher than the national average; that difference is statistically significant. To reduce this rate, transition-of-care strategies are being developed and deployed at Cleveland Clinic. These include predischarge needs assessment, improved discharge processes (patient education, relay of discharge information to receiving providers) and postdischarge follow-up, including continued clinical management support.

20

The Centers for Medicare and Medicaid Services (CMS) calculates two AMI outcome measures: all-cause mortality and all-cause readmission rates. Each are based on Medicare claims and enrollment information. Cleveland Clinic’s performance appears below.


Outcomes 2011

Ischemic Heart Disease - Cleveland Clinic

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